U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Unintended inconsistencies in medication regimens occur with any transition in care...
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Device-related Complications (1)
Diagnostic Errors (4)
Identification Errors (4)
Discontinuities, Gaps, and Hand-Off Problems (110)
Medication Safety (243)
Medical Complications (7)
Surgical Complications (4)
Transfusion Complications (1)
Psychological and Social Complications (1)
Australia and New Zealand (8)
North America (217)
Clinical Guideline (1)
Journal Article (198)
Newspaper/Magazine Article (34)
Press Release/Announcement (2)
Special or Theme Issue (2)
Web Resource (1)
Epidemiology of Errors and Adverse Events (103)
Active Errors (46)
Latent Errors (19)
Near Miss (2)
Approach to Improving Safety
Health Care Providers (217)
Health Care Executives and Administrators (198)
Non-Health Care Professionals (50)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (12)
Ambulatory Care (58)
Outpatient Surgery (2)
Patient Transport (1)
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Engaging patients in medication reconciliation via a patient portal following hospital discharge.
Heyworth L, Paquin AM, Clark J, et al. J Am Med Inform Assoc. 2014;21:e157-e162.
What happens to the medication regimens of older adults during and after an acute hospitalization?
Harris CM, Sridharan A, Landis R, Howell E, Wright S. J Patient Saf. 2013;9:150-153.
Hospital-based medication reconciliation practices: a systematic review.
Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Arch Intern Med. 2012;172:1057-1069.
Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge.
Ziaeian B, Araujo KLB, Van Ness PH, Horwitz LI. J Gen Intern Med. 2012;27:1513-1520.
Medication regimen complexity and hospital readmission for an adverse drug event.
Willson MN, Greer CL, Weeks DL. Ann Pharmacother. 2014;48:26-32.
Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.
Kripalani S, Roumie CL, Dalal AK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Ann Intern Med. 2012;157:1-10.
Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists.
Lee KP, Nishimura K, Ngu B, Tieu L, Auerbach AD. Ann Pharmacother. 2014;48:168-177.
Quality improvement through implementation of discharge order reconciliation.
Lu Y, Clifford P, Bjorneby A, et al. Am J Health Syst Pharm. 2013;70:815-820.
Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.
Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-1895.
MARQUIS Medication Reconciliation Resource Center.
Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). Philadelpha, PA: Society for Hospital Medicine.
Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.
Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.
Prevention of adverse drug events in hospitals.
Zhu J, Weingart SN. UpToDate. February 17, 2015.
Hospital discharge documentation and risk of rehospitalisation.
Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.
Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up.
Armor BL, Wight AJ, Carter SM. J Pharm Pract. 2014 Oct 13; [Epub ahead of print].
Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.
Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.
Patients taking their own medications while in the hospital.
PA-PSRS Patient Saf Advis. June 2012;9:50-57.
Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.
Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.
Errors in medication history at hospital admission: prevalence and predicting factors.
Hellström LM, Bondesson A, Höglund P, Eriksson T. BMC Clin Pharmacol. 2012;12:9.
Health literacy and medication understanding among hospitalized adults.
Marvanova M, Roumie CL, Eden SK, Cawthon C, Schnipper JL, Kripalani S. J Hosp Med. 2011;6:488-493.
Effect of admission medication reconciliation on adverse drug events from admission medication changes.
Boockvar KS, Blum S, Kugler A, et al. Arch Intern Med. 2011;171:860-861.
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